Witelon Collegium State University	
	
ACCOMMODATION FORM  FOR  INTERNATIONAL STUDENTS

		ACADEMIC YEAR 20…./20….	
PLEASE WRITE CLEARLY AND USE CAPITAL LETTERS
Family name		First name		
Date of birth (dd/mm/yy) 		Gender	Female   Male  	
Place of birth 				
Nationality		Home address		
Passport number/ ID:		City		
E-mail    		Post code		
Phone		Country 		
Home University		
Special remarks (For example: roommate’s name,  ect.)		
Person to contact in case of emergency	Name:	Phone :    	E-mail:	

Duration of stay in Witelon Collegium State University  
Please choose one option.
  Full academic year:   from ………………….. to …………………………
  Winter semester:       from ………………….. to …………………………
  Summer semester:     from ………………….. to ………………………… 	

Accommodation  cost
Dom Studenta  ( Hall of residence). Address:  ul. Mickiewicza 10,  59 -220 Legnica, Poland
The University guarantees a place in the room.
Indicate your preferences (it  does not guarantee you’ll  get a room of your choice).	
Room	Per month	
                                                    Rooms with shared bathroom and a kitchen on the floor	
	Double room	470 PLN per person	
	Room for three	400 PLN per person	
                                                    Rooms with bathroom and a kitchen on the floor	
	Double room	495 PLN per person	
	Room for three	430 PLN per person	
	Room for four	365 PLN per person	
                                                   Rooms with bathroom and kitchen	
	Double room	535 PLN per person	
Student has to pay a security deposit of 300 PLN  in beginning (it will be refunded if the accommodation is vacated without any damage).

Please return this form to:	Witelon Collegium State University
International Relations Office	
Address:	Ul. Sejmowa 5A,  59-220  Legnica,  Poland 	
spring/ summer semester	not later than before  31 of May	
autumn/winter semester	not later than  30 of November	

Date:  /….../….../…                                           Student’s signature: …………………………………….